Innovative Models of Care Episodes of Care Migrating from Fee-for-Service to Fee-for-Quality/Value Bundled Payment Summit June 2014 Lili Brillstein, MPH Director, Episodes of Care Horizon Healthcare Services, Inc. 1
The Triple Aim Through collaboration, we are helping to create an effective, efficient and affordable health care system We are achieving better health and better care at lower costs Patient-Centered Programs: Patient-Centered Medical Homes (PCMH) Pediatric Patient-Centered Program Accountable Care Organizations (ACO) Episodes of Care (EOC) 1 2 Triple Aim Enhance the Patient Experience 3 2
Growth of Horizon s Patient-Centered Programs January 2012 January 2013 January 2014 3
Over 500,000 Horizon members and 2,800 doctors Over 500,000 Horizon BCBSNJ members are benefiting from these patient-centered programs. More than 2,800 doctors and 900 practice locations are participating in these programs. 4
Episode of Care What is It? A single practice or physician acts as the conductor who orchestrates the fullspectrum of care for a service or procedure. The care spectrum/time line is defined. Includes all services related to a particular procedure and/or diagnosis within a defined time period. Program goals: Greater collaboration between provider and payer. Improve care coordination. Improve clinical outcomes. Increase patient satisfaction. Reduce the total cost of care. 5
From Pilot to Scalable Program As of January, 2013, only total hip and total knee replacement episodes, our original pilot episodes, were implemented. At year-end, there were four new episodes launched: Knee Arthroscopy, Pregnancy, Colonoscopy, Adjuvant Breast Cancer. # Participating Providers Episode of Care 2013 Start 2014 Start Total Hip Replacement *37 59 Total Knee Replacement *37 59 Knee Arthroscopy 0 33 OB 0 190 Colonoscopy 0 34 Breast Cancer 0 17 * Includes new conductor specialty - Anesthesia 6
How Did We Do It? Speed to market Reduction of administrative burden Established quality measures Established member satisfaction metrics Established financial targets 7
Speed to Market & Reduction of Admin. Significant Standardization Standardized Addendum FFS rate stabilization 3 year arrangements Minimum 30 episodes/2 years Standard definitions/algorithms Instituted Practice Level Budgets Case mix adjusted by practice Measured against practice history/mean Standardized program to include all cases for shared savings Standardized Recruitment Process Including some mass mail introductions/invitations 8
Speed to Market & Reduction of Admin - Continued Standardized Quality Metrics Eliminated data entry of 200+ quality metrics and associated administrative costs Identified key quality indicators to assess program at high level 3 generic metrics across all episodes Readmission Rate, Patient Education, Care Coordination 1-4 episode-specific metrics New EOC launch time reduced from >1 year to between 12 & 26 weeks 9 9
Quality Measures are Established Quality Advisory Committee Reviews and approves measures, thresholds and performance Recommends Corrective Action Plans, as required Each Episode Contains (3) Standard Quality Measures: Pre and Post Procedure/Surgery(Trigger) Patient Education Care Coordination and Shared Decision Making All Cause Re-admission Episode Specific Quality Measures: All Episodes will have one-to-four episode-specific measures 10
Member Satisfaction Metrics are Established Patient Advocacy Council Reviews and approves measures, thresholds and performance Recommends Corrective Action Plans, as required All members surveyed by 3 rd party vendor Standard Key Measures Overall patient satisfaction Likelihood to recommend Episode-specific questions 1-4 related key indicators 11
Financial Targets are Established Informatics & Clinical Innovations Reviews and approves measures Reviews and approves thresholds Reviews and approves performance Recommends Corrective Action Plans, as required Practice level vs Patient Level Budgets Pilot Phase - Patient Level Risk Adjusted Scaled Program - Practice Level Case Mix Adjusted Next Regional? Budget Calculation Methodology Episode simulation of two years of practice history, using historical claims Low 5 percentile and high 5 percentile of episode costs excluded Mean established and reviewed for practice level budget establishment Medical cost trend applied Outlier protection 12
How It Works Retrospective Program All providers of care within the continuum of the episode are paid at their contracted fee for service rates Episode assessment is made, post episode, and after a three month claims run out period Quality targets reviewed Member satisfaction thresholds reviewed Financial review to determine if aggregate of the episode actual costs were below the established targets 13
How It Works - Continued Quality metrics measured and reviewed by Quality Advisory Committee (QAC). If any metrics fall below established thresholds, corrective action may be recommended. Patient satisfaction measured and reviewed by the Patient Advocacy Council (PAC). If any metrics fall below established thresholds, corrective action may be recommended. If the actual costs come in below the established targets, outcomes-based payments are calculated for shared savings, based on the percent of shared savings outlined in the provider s addendum. In the future, it is anticipated that Horizon-BCBSNJ will offer an option for prospective payments related to episodes (i.e., bundled payments). 14
2014 Strategy Transformation Leverage expertise of PCMH Transformation Coaches Operationalization Standardize reporting Program Expansion Further Standardize Processes Recruitment Reporting Leverage Established Partners Create cadre of Program Ambassadors to market program Outcomes data sharing with PCMHs & ACOs Medical Neighborhood (encouraged use of EOC partners) Integrate care across continuum Overall cost modification/reduction Model Value vs. Volume Benefits 15
New Horizon product focused on PCMH/ACO No PCP selection is required. However, members receive additional cost savings when they select a PCP who is participating in our patient-centered programs. Physicians and other health care providers who participate in our patient-centered programs will be identified on the Horizon BCBSNJ Online Provider Directory. 16
Engaging everyone! Continuum of Care 17
Questions? 18